Healthcare Provider Details

I. General information

NPI: 1821972548
Provider Name (Legal Business Name): DERMATOLOGY SPECIALISTS OF GRAND RAPIDS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2025
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 EAST PARIS AVE SE STE 104
GRAND RAPIDS MI
49546-3680
US

IV. Provider business mailing address

43151 DALCOMA DR STE 4
CLINTON TOWNSHIP MI
48038-6306
US

V. Phone/Fax

Practice location:
  • Phone: 586-876-2345
  • Fax:
Mailing address:
  • Phone: 586-876-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ILTEFAT HAMZAVI
Title or Position: M.D.
Credential:
Phone: 810-650-0995